Author: Jsoze

We will always love you

April 2021

The number was typed into my phone, thumb hovering over iPhone call button icon. For at least a minute I was frozen. It was my patient’s daughter. Three in the morning. This is a total DSP, I thought. Parlance for “day shift problem”. Calling families is a total DSP but if someone dies or is actively trying to die you have to do it. Hell. But there was little optimism he’d make it through the night, so. I inhaled deeply and exhaled slowly. Pressed the button. I hoped she wouldn’t answer. Rang a few times and I had that thank god feeling until someone said hello. Shit. I told her I was doctor so and so, a resident at the hospital, working in the intensive care unit. She asked about her father. I had to tell her with muted emotion that he wasn’t going to make it much longer. Do you want us to continue complete resuscitation measures, i asked.

I just, I just need a minute, she said. 

She came back. Explained to me how they thought he was doing better, his kidneys were improving and the numbers indicated his infection was clearing up. He was doing better, she said, voice choked up from the burst of emotion one feels when they hear that someone they’ve known their whole life, someone who made them who they are, is for all measures, gone. And will never come back. 

I got angry. How the hell did anyone paint a picture that he was doing better. Why give this woman and her family that hope. I professionally sucked all of that hope of out them. All I could think to say was I’m sorry. What can you say: I’m sorry. 

Whisper in his ear, she pleaded. Please just tell him. Tell him it’s the fourth quarter. It’s the fourth quarter, you just have to keep going. He loved football. That was his favorite saying, she cried. Just tell him that. Tell him it’s the fourth quarter and he can’t give up now. Tell him to keep fighting – it’s the fourth quarter. 

I removed the phone from my face and flexed my abdomen and tensed up to stop this flood of feelings. Fuck, stop. I don’t want to do this. I don’t want to tell you this. Anyone in medicine knows when the point of no return has been reached, and – he’s there. I’m sorry. I’m so impossibly sorry. This patient on my list is your dad and you love him and I’m so, so fucking sorry. There is no alternative. Stop humanizing this. Stop making this so much harder for me. I looked through the glass wall to his room and looked at the man, tube in his throat, machine mechanically pushing air into his lungs, nurses huddled around his body overriding the “max dose” setting on the drugs that were keeping his heart pumping, on three pressors and maxed vent settings and dying. I’m so sorry. I’m sorry. I’m sorry. God. 

Stay with me on the phone, she said. Talk to me. 

Like a movie flashback I remembered something I hadn’t thought about in ten years. Why. I remembered first time I wanted to be a doctor. The first time I told myself I want to be exactly where I am right now.  

My childhood, I had it good, make no mistake about that. My father was a surgeon. But my parents divorced when I was young. My father lived far away. I was a problematic child. My mother, a mother of four boys, four wild and reckless boys, was tasked with raising us essentially alone. Her parents, my grandparents, gave up their retirement beach condo and moved back to raise us while my mom worked. My grandmother was my second mother growing up. She was the one that made sure I did my homework. Ate my vegetables. Old school Italian woman who would whip my ass with the spatula if I talked back. But she had a sense of humor and love that she carried with her. She did everything out of pure love to help her daughter, my mother. Gave up her last years to raise some ungrateful kids. 

One afternoon I was in the basement. Doing kid things like playing video games on my PS2 or GameCube or whatever at the time. Phone rang – landline like we used to have. I picked up and it wasn’t for me. I stayed quiet and eavesdropped. My grandfather answered at our home. It was the sherif. She had been in a car accident. She was taken to the hospital. Critical condition. At my adolescent age I tried to surmise what this all meant and I didnt know but I understood the tone. The feeling. 

Later that night my aunt sat me down and explained everything to me because my mom couldn’t. Grandma was on a breathing machine and they had some hope that she would recover and she told me to pray so every night I lied in my little childhood twin bed and locked my fingers in the prayer formation and prayed to god that my grandma would get better. Through the vents at night I could hear my mom crying. Smell cigarette smoke. For nearly thirty days. My birthday was three days before this had all happened. She had given me card, with a little message of well wishes and love and above all — a plea to make my mom proud someday — signed: 

Love, Nana

I remember opening the card on my birthday and not reading a single word that was written and seeing a $50 bill that I shoved into my pocket before discarding the letter. It was the last moment I spent with her and I hated myself for it. I’d go in the bathroom and run the shower for an hour just so I could cry without inhibition where no one would hear me. I read it every night she was in the hospital on the ventilator. All thirty days. Until I had heard my mom cry so much that one night I prayed to god that he would take her and bring my mom some closure. I dreamt of my grandma that night and she said: it’s okay, I love you, it’s okay. My 14 year-old brain trying to make sense of it all. 

The next day the decision was made to pull the plug. I still vividly remember it all. My mom took me and my brothers to the hospital to see her. Cords and tubes spilling out from her body. It wasn’t my grandma anymore. She was such a beautiful and prideful woman. Even at a young age I knew: this is not life. Later that day, she was gone. 

I cried and cried and cried clutching that birthday card. Hating myself for not appreciating her for all she’d done for me and all the love she’d given. For not telling her how much she meant to me. So I told myself I had to become a doctor. Not because I had any delusional ideas of saving people that couldn’t be saved. But I had to become a doctor for that moment. Where you had to break the news. This moment. Now. This is what you were born to do.

I’m sorry. I’m here with you, I said, as a tear rolled down my cheek. Why don’t you tell me your favorite stories about him.

When does it get better

April 2022

When does it get better, she asks. 

I don’t know. I mean, a switch doesn’t flip one day. When someone you love dies you don’t hear a eulogy and think to yourself, gosh, it all makes sense now. You don’t say a prayer and find some sort of divine comfort. Nothing helps. It sucks. Nothing is going to happen for you. Life isn’t a Disney movie. Shitty things happen. And nothing will ever convince you it doesn’t suck. You are doomed. Doomed to carry it with you until other things and people start occupying your heart. A tree dies and a new one doesn’t spring up from the ashes in the morning.

Still, you can be sad and angry all you want. You deserve to be. You should be. This whole thing sucks. So. Obsessively ruminate over why and what you could have done differently until your brain breaks. Mentally rehearse conversations you’ll never have with people who don’t care you exist. Scream into the void. Drive yourself insane. Go crazy.  For as long as you want. For as long as you need. 

But you have realize. You’ll get off work one day mad about something innate to residency while someone in your dream program is feeling the exact same. You’ll despair over some program that didn’t want you. After two years you’d be counting down the days until you could leave anyways. No matter what you’ll be physically exhausted from long hours in a gloomy hospital. 

You can shake your fist at the sky but it’s still blue and there isn’t a damn thing you can do about it. You can scream and curse but beautiful songs and melodies will forever drown you out. One day you decide to go for a walk with good music in your ears and the sun is shining and a wide-eyed puppy scampers at your feet and jumps on your knee, its tail wagging all joyous and such. I promise you, that dog doesn’t give a damn about the match or your residency. The sun sets and it looks like bob ross himself painted the sky and it’s still picturesque, despite you. Go ahead and try. But you can’t escape the small pleasures. The beauty of it all. The watermelon on a summer day; it’s still sweet. Your mom is still excited to hear your voice on the phone. A baby smiles at you in line at the grocery store. You laugh with new friends. Life is still happening.

All is not lost.

Memories & Merlot

January 2021

One day you pick up the phone. It’s the dean of a medical school. He congratulates you on your acceptance into their medical school. You are so overwhelmed with joy that one lonesome tear crawls down your cheek. You let it roll. And you wipe it away quickly because you’re bartending and absolutely no one wants to see their bartender cry. For god sakes, no emotions. But you’re so happy you want to cry. You call your mom and your dad. You try to contain it but every cell in your body is bursting with euphoria. Your life changes. You have a future. You are going to be a doctor. This is one of the best moments of your entire life. Congrats.

Then one day you wake up on the floor, alone in your apartment. It’s emptiest of feelings. You hate who you’ve become. The morning light spills through the blinds to the patio. It burns your eyes. Empty bottle of nine dollar Merlot on your coffee table. Your old MacBook is in front of you, last open to text message threads from friends and people you loved who only exist in these archives. You read them to relive old memories that no one aside from you even gives a shit about. The texts you sent in 2017 read like they were sent from someone else. An entirely different human being.

You lay there, on the floor, staring at a screen with jaded eyes. Every Friday night alone in the living room. Sipping cheap aldi wine. You play music that reminded you of times of old, songs that soundtracked these distant eras. You stay up, late at night, to attentively watch YouTube videos of 4K tours of old cities you’d lived in. 

Can you imagine anything more pathetic. Seriously, what an absolute loser. Oh you’re a young single doctor how awesome they say. No, I hate myself and spend all free time reminiscing on memories of when I was happy. Mad at yourself. Alone in an apartment wine-tipsy searching for YouTube videos of cities you lived in. Just to remember. Desperately trying to breathe some life into memories that were rapidly being replaced. Memories of when life was full of fiery energy and rose colored emotions. Replaced by grey monotony and purposelessness and longing for just one more day with people you care about. Conversations that make you want to bang your head on a concrete wall. How’s my 401k. The stock market, it’s really something right now huh. Oh my god, what about the gas prices and how bout air fryers. You gotta get one. 

You watch the videos and remember. On the shaky hand-cam footage you see the little coffee shop on the corner where they knew your name and order: a chorizo breakfast burrito with an iced coffee. You see the streets you’d stumble down in a euphoric stupor giggling with the people you could laugh with until the sun rose. That little cafe you went on a date before coming home to cozy up and watch a scary movie. You can close your eyes and feel it. You stare at these images misty-eyed. Pretend for just a fleeting moment that you are there. You remember the warmth of it all. Close your eyes and listen to the music and let images play on your eyelids and meditate on it and for a few seconds, just a few seconds, it feels like you there again and it feels so, so fucking warm.  Then you open your eyes. You realize it’s no more real or tangible than a fantasy dream. And it just hurts. 

And in this daze at three in the morning, alone in a dimly lit apartment a thousand miles away, lips stained red from the merlot, you wonder how you got here. You mentally beat yourself for what you should have done differently until you feel so defeated that you become tired and numb. You miss the people and memories but most of all you miss that feeling of hope and wonder. You miss the old you as if it were an entirely different person. It was someone else. You gaze into the black mirror and think I am not me at all. What happened to that bright-eyed kid. The son and brother who was so full of pride. The friend with endless jokes and smiles and banter. The genuinely happy and charismatic human being. You lay there on the floor and realize you are so far from gone. You wish with every bit of emotion in your soul that it will come back, some day. And it hurts but… it’s something. It’s a feeling. And that is what you crave. A feeling. Sadness, a human feeling. You do it to simply feel human again after a another week of feeling anything but that. A week of no emotions. An intern amongst dozens who doesn’t actually matter to anyone. A thousand miles from home and everyone you care about.

Then it’s four am and you’re sobbing watching these YouTube videos while “Its Too Late” by Carroll King plays on the Amazon Echo. You wake up on the floor, eyes swollen, and you’re hate yourself for devolving into such a nostalgic mess of sadness, but, it’s the most human moment of your week. It’s all you have. And you’ll repeat this again and again and again. 

One day life will be better. Make someone smile tomorrow. Just keep going.

Do it

You just need to do it, she said.

Across the high-top table, she was leaning forward, hands clutching a glass of Hendrick’s and soda with lime. Staring into my soul with eyes black like the summer date-night dress she was wearing. Her eyes vindictive yet soft. Honest. It was candid and surreal. Like a random scene out of a David Lynch film.

My eyes were tired and defeated. I explained to her. My story didn’t have a triumphant ending. My journey was not a hero’s journey.  No lessons learned. No happily ever after. No victory and no joy and no pride. I just exist. Every question I ask myself just leads to more. More what ifs. I was once such a happy and hopeful kid and then, I don’t know, it’s hard to explain. 

Okay, there was a period in time, years ago… I was up there, I said gesturing towards the sky. I.. flew too close to the sun. Reached the Roche limit, you know? Ever since, I’ve just been falling and catching branches along the way.

Well I think you’ve caught some pretty amazing branches, she said. This branch you caught is the top of someone’s tree.

Maybe she’s right. But I object simply to be a self defeating contrarian and ramble about how my story has no value to anyone. When I tell her that I am no one’s role model, no one to seek advice from, that I constantly feel like a fuck up, she doubles down. That’s the point, she says. She just smiled. And in this insignificant moment, something hit me. A sweeping comfort. I am gifted with the perspective of experiencing all the horror and hilarity of everything this niche of life has to offer.

I think she was trying to make me feel good. Doesnt matter. Something clicked. This was six months ago. But I started writing again. Not with any goal, with any narrative, with any point to prove. Certainly no advice. It was for me. I just started writing my thoughts, my absurd rants and raves and let that part of my brain take over. It felt so good. Eventually I amassed a collection of these writings; enough where I could flip through them and read for hours. Some make me laugh and some make me want to cry. Real feelings, many of which I believe are universal to everyone on this path, distilled into little collections of word.

Long after that night, I couldn’t shake her words and her conviction. She was right. There is a story to tell. It sucks, but. Movies where the good guy wins every time suck anyways. Played out. There are enough residents on Tik Tok and #medtwitter humble bragging about how sick and triumphant and fulfilling their life is. Meanwhile I practically have to meditate on a mountain to convince myself I don’t suck and I’m not a failure. And currently I’m trying to figure out how to remain a sentient and mindful and empathetic human through all of it. And become the best doctor I can be. This faction needs a voice. Maybe its a tragic comedy. Who cares. Probably no one. I’m gonna write about it. 

Welcome to the next chapter.

Match Week: Monday. 16.03.2020.

We found out the world was being shut down due to the virus after Sunday brunch. Everything we were looking forward to — match day celebrations with warm hugs and happy tears, adventurous fourth year travel plans before residency, that we made it feeling of graduation with all the pictures with the people who were so proud of us — all canceled. So naturally we gathered together at my friend’s apartment for a final social gathering before retreating to our homes to bunker down for the ensuing social isolation. No one knew what was coming, but. 

What else could you do.

Each hour escaped quicker than the last, the stories spilled, the laughs bellowed and the glory of the you matched email gleamed in plain sight like the finish line at the end of a marathon. My classmate and I sat on the patio, drank wine, and debated where on our rank lists we’d fall like children anticipating what toys would lie beneath the tree on Christmas morning. But I knew where I was going. Saw the program director a few days prior at the outpatient surgery center. He ended our conversation with, “talk to you next week”. Asked my PM&R attending if I was overanalyzing it. She heard it too. She said, no, you know what he meant, enjoy your weekend and congratulations. I was at peace with everything. I was in love with everything and everyone. I was surrounded by people I love on the eve before the best day of my life. A genuine childlike smile never left my face. I was nothing short of euphoric. As the sun sank behind the horizon and darkness consumed the sky, my thoughts drifted from playful conversation to mindful introspection of the journey..

All those lonely hours spent studying and memorizing and agonizing over tiny details to ace tests that would allow me to pursue my dreams. Quizzing myself over and over and over again on the anatomy before surgical cases. Hand-tying thousands and thousands of knots on random household items until I could do it with my eyes closed just so I could impress when I finally got my chance. I was smiling all along. Internally crying. Tears of joy, tears of pride, a pat on the back, a congratulatory — you did it.

At this moment, I was in love with life. One moment in my timeline in which I could delete the stress like an old text message thread and simply say, I’m proud of myself. All I could think about was the joy of the ensuing week. How proud my friends and family would be. My mother and father, Jesus, this was the moment in life I can finally repay them and say — thank you, I love you, I did it. But most importantly, how proud of myself I’d be when I finally got that email. No one aside from me knows what I put into this, what I went through, and how triumphant this moment would be. 

Eventually, friends left, others went to bed, but my little brother and I stayed up until four in the morning watching movies. Rotations were canceled, so why not. We both understood the gravity of how special the moment was. We were going back and forth, laughing, talking, riffing off the glory of the moment. Tomorrow was a snow day. And tomorrow was Christmas.

At some point, I crept into bed. Nestled up with the pups. I didn’t have a single dream that night. My eyes cracked open and I groggily checked the time on my phone – 9:40 AM. Jumped out of bed like I was a late to a job interview. Paced around the apartment for a half hour, refreshing my email just in case they sent out the results early.

Alexa, play Let It Happen by Tame Impala, I said. Alexa, volume ten.

I felt the pounding rhythm and guitar riffs pulse through my arteries. Heart thumping louder than the drums. Euphoria leaking from my pores. I ran around the apartment, pacing, jumping up and down, dancing around like I was a football player in the locker room before the Super Bowl. For nearly an hour straight I did this. Playing the songs that reminded me of different eras of this eight year journey. Looking down at my phone every minute to see how much time was left. It felt like my entire life had been leading to this moment. Every minute I had spent studying during the past, what ten years, it was for this. Today was the payoff. Alexa, play Seven Nation Army. Alexa, play Reptilia by The Strokes. Alexa, play 30 by Danny Brown. Alexa, play All My Friends by LCD Soundsystem.

I continued jumping around like I’d just consumed an entire container of pre-workout mix. Singing along with the songs. With five minutes remaining she looked at me. And I’ll never forget that look for as long as I live. Her eyes wide and glossy. She didn’t say any words. She just stared at me. And then shook her head. Her lips trembled and her mouth moved. A single tear slid down across her cheekbone. She shook her head… “no”.

For the first time in an hour, I stopped moving. I looked down at my cell phone. Email notification read, 2020 Main Residency Match Results. I opened it. Those bold letters.

We are sorry, you did not match to any position.

I read it again.

We are sorry, you did not match to any position.

And again.

We are sorry, you did not match to any position.

And again.

We are sorry, you did not match to any position.

I stood still. Staring at the wall. No expression on my face. Lost in confusion. Drunk on defeat. Melting into the floor with helpless despair. Ankles strapped to cinder blocks sinking to the bottom of the ocean while the light of the sun on the surface grew more distant until everything faded to black. They were unsure of what to do. Or say. They just stared at me. I couldn’t speak. I wasn’t even making real thoughts. There was nothing in my brain. Nothing. Uncomfortably numb. Eventually trying to convince myself it wasn’t real. Like a dream when you’re falling, but there was no ground to land on. Nothing to wake me up. It wasn’t going to end. There was no waking up to realize everything was okay. This nightmare was real. And it had just begun.

The Med Student’s Guide to Emergency Medicine (Part 2)

Zesty Mortdon is a recent medical school graduate who will start his emergency medicine training in July. In part two of this series, he addresses the competitiveness of EM, gives insight into the application process, touches on SLOEs, and gives advice on how to stand out on audition rotations. If you haven’t checked out part one yet, click here: The Med Student’s Guide to Emergency Medicine (Part 1)


 

Competitiveness

This is a hard question to gage. I would recommend looking at the NRMP match data. Specifically, look at average board scores and contiguous ranks (how many interviews you need to aim for to have a certain percentage of matching). Those will generally give you the best idea of how competitive EM is and how competitive you are within the applicant pool.

Historically, EM is mid-tier in terms of competitiveness. In very broad strokes, it’s less competitive than derm or ENT, on par with anesthesia and general surgery, and more competitive than FM and IM.

Competitiveness is also largely dependent, as mentioned above, on your away rotations and SLOEs. Killer rotations with solid SLOEs can definitely make up for a lack-luster Step 1 score.

 

Audition rotations

Unlike other specialties, auditions (also known as acting internships [AI], sub-internships [sub-I], whatever you want to call them) are extremely important for EM. This is mainly because of the need for SLOEs, which are discussed below. But auditions are also important as you get to know if a program is a good fit for you in terms of resident support, faculty set-up, and ED structure (nursing staff, scribes, EMR, dictation help, equipment, etc.)

At a minimum, you need two auditions. This typically includes one rotation at your home institution and another at an outside program. This is assuming your home institution has an EM residency and you can rotate with them before September 1st. If your home institution does not have an EM residency, or you cannot rotate with them before September 1st, you need to rotate at another outside hospital for an audition. This is because you need at least two SLOEs before applications open, and these should come from programs with an EM residency (further discussed below).

I encouraged third years to go on as many auditions as they could afford and mentally handle. These are fantastic opportunities to get to know programs and for them to get to know you. However, they can get expensive as you’re paying double rent and are in a city that may be more expensive. Even more, you have to be on you’re “A game” for all of these rotations. Think of them as month long interviews. One bad shift with a resident or attending can be detrimental. However, expectations are typically geared toward personality and teachability traits more than gross medical knowledge. Be a hard worker, personable, likeable, and willing to learn.

Where you choose to do auditions is a debated topic. Some people will argue you should do them at institutions in which you are extremely interested. Some argue you should do them at programs that write solid SLOEs. Some argue you should do them at a wide variety of hospitals to cover your bases (i.e. one at a big academic level I trauma center, one at a community hospital, one at a DO program if you’re an osteopath, etc.). I was a fan of covering your bases, though I wonder in hindsight if my application would have been stronger had I done rotations only at big centers. I ended up doing a rotation at my home institution (small, non-levelled community center), another at a big level I academic center, one at a medium sized level II community hospital, and my final at a big county/academic, level I program (ended up matching here). I got great exposure to all of the different program types and was well informed for the type of program in which I wanted to train. But I can’t help but wonder if the top tier programs missed my intentions compared to kids who only rotated at huge tertiary centers. While I advocate for my method, I can’t definitively say this is the best way to guarantee you match.

 

SLOEs

https://www.cordem.org/esloe/

The main utility of audition rotations is to obtain standard letters of evaluation, or SLOEs (pronounced “slow” or “slow-e” depending on who you ask). These letters are standardized letters of recommendation that assess you in comparison to other medical students who rotate through a given hospital. They have general questions, but also have a section that asks how you rank in comparison to other students. The options are top 10%, top 1/3, middle 1/3, and bottom 1/3. It’s important to note that while a top 10% SLOE looks best, a bottom 1/3 SLOE does not necessarily kill your chances. Some programs may even write a glowing review, including how even though you received a bottom percentile SLOE, you would make an excellent physician.

You need at least two SLOEs from programs with a residency. Three SLOEs are ideal, with a fourth letter of recommendation either being a fourth SLOE or an independent letter that is high quality and personal (I prefer the latter here). You need at least one SLOE to be written and submitted by time your application is submitted (mid-September). If you do not have one by this point, most programs will consider your application incomplete and won’t review it (though some will if you contact them and tell them SLOEs are incoming). Most programs are okay with you only having one SLOE in by time applications open and will view your application accordingly. However, it is still technically incomplete as most programs require two SLOEs. Ideally, you should have two SLOEs uploaded by time applications open. I strongly advocate for this plan. I spoke with a EM program director at a big academic center, and he said when he is faced with the task of sorting hundreds and hundreds of applications, he sorts them into three initial categories: complete, incomplete, and definite no. He said it greatly benefits you to be in the complete category, as they will be considered first. And with the pile being so big, he often finds so many quality interview choices that he does not make it all the way through the incomplete pile. This is only one PD’s opinion and style, and plenty of my colleagues matched with only one SLOE in by September. But his program was solid and he had great residents, so this bit of advice has stuck with me.

Make sure to allot enough time for the programs you rotate at to actually write the letter. If you finish your second audition September 10th, this may not be enough time for your SLOE author to submit. As a rule of thumb, I would recommend finishing your auditions by the end of August at the absolute latest. This will give your last SLOE author about two weeks to submit a SLOE.

In that same vein, who should you ask for a SLOE? This will change based on the program but is usually easy. All of these programs realize you need SLOEs in order to apply. The vast majority have a clinic clerkship director or other designated attendings that assume you will need a SLOE, and have a procedure in place to assess you (i.e. you may have to have an attending or resident fill out an evaluation after every shift you work, with all of the evaluations being conglomerated by the SLOE author to compose your letter). Regardless, this should be one of the first questions you ask when you are setting up auditions! In the off chance there is no designated process, you should ask the attending you’ve spent the most high-quality time with for a SLOE. Ideally, this will also be the attending you liked best. These are important, so make this choice carefully if you’re at a rare program that doesn’t have a SLOE-writing process in place.

Switching gears, you can get a SLOE from a hospital without an EM residency program. They have special SLOEs for this situation (see link above). I personally used this as my third SLOE since my home program did not have a residency program. However, the jury is out regarding how these SLOEs are weighted compared to residency SLOEs, and if you are better off asking EM physicians in this situation to write you a traditional letter of recommendation. I got positive feedback in multiple interviews for having three SLOEs (even though one was non-residency) and having a fourth letter from a general surgeon that I really got along with and respected immensely.

 

How to impress and succeed on EM rotations

The biggest thing to remember when on your AI is that most residents and attendings don’t expect you to know everything. I would argue the main thing they’re looking for is someone they can get along with. You’re going to be working with these folks at 3AM on Christmas Eve. They want someone they like, or at least can tolerate, during these tough days. You can teach medicine. It’s much harder to teach personality.

So to impress and succeed, it’s important to be personable. Be easy to get along with, be teachable, and show willingness to learn. You don’t have to know the differential and work-up for myoclonus. But you have to show the motivation to learn it and be able to work it up when the next patient with myoclonus shows up in a room.

Now there are ways to get some brownie points on these rotations. Anything you can do to free up time for residents will be huge. Know how to suture and how to I&D an abscess without supervision. Follow up with patients after treatment. Someone came in with nausea and was given Zofran? Follow up in a half hour and tell the resident how they’re responding. In that same vein, keep an eye on labs/imaging for each patient and let the resident know of any abnormalities. To do this, try to have access to a computer and EMR. Always ask for feedback after a shift.

One last thing: try and work at least one shift with the program director (PD). Most rotations will work this in for you, but in the event they don’t, it can be extremely useful to work directly with the PD. Putting a face to a name is beneficial. It’s also important to see how the PD manages the residents and how his or her personality mingles with yours. Finally, SLOEs from PDs are phenomenal. For one of my auditions, I asked the PD for a SLOE instead of the designated attendings. This was a gamble. I risked coming off as a student that doesn’t follow protocol or who was bothering a PD to do something another attending was delegated to do. So, I can’t recommend you do this. But if you got along well with the PD and built a solid rapport, it might be worth asking. Just assess your relationship with the PD across the rotation and go from there.

 

 

Can I match into family medicine and then pursue EM after that?

Yes.

This is a great question and one many of my classmates considered. American Council of Emergency Physicians (ACEP) puts out an annual compensation report, which includes how many EM jobs are available to FM physicians. As of 2018-2019, jobs open to primary care board certified docs was at 43%.

The catch here is that these jobs will likely be at small, non-levelled, community hospitals. It will be very difficult to find get a job in a big level I trauma center or at a university. It will also be hard to get jobs, no matter the type, in popular cities (i.e. LA, NYC, etc.).

I’m not entirely up to speed on the process of entering EM through primary care. From what I understand, some programs will offer a fellowship-like training period after residency for you to train more in the ED. It’s probably worth checking with someone who pursued EM this route.

 

Closing thoughts and advice?

My biggest advice is to make judgments from your own experience and not from what you read or hear. I’d rather trust my own experience than that of others, no matter how ubiquitous the thought. Not to say you shouldn’t listen to other’s advice or opinions, but try not to take their experience as definitive truth.

The first step in choosing a specialty does not have to be surgery or non-surgery. Think of other factors that drove you in to medicine. Do you want sick patients? Do you want your own patients? Do you want procedures? Do you want to take call? The list goes on. But again, do not default to the commonly used techniques or opinions. Take a step back and think what works best for you.

Get auditions set up early! You should aim for two SLOEs by time applications open in September. This is vital to your chances of matching. Some may argue you only need one, but I strongly suggest getting two.

When you’re on auditions, its not necessarily about how much you know. It’s more about how you mesh with faculty/residents, how teachable you are, and how much you’re willing to work.

Try to work at least one shift with the program director.

Check NRMP match data to gauge your competitiveness in this field. But remember, a killer audition can immensely improve your chances even if you’re numbers are a bit weak.

While you may have a preference for academic, community, or county residency programs, try to judge where you want to go by how well you fit in with the residents/faculty. Co-residents and faculty that are supportive and good teachers will lead for a better experience than program type.

You can practice in the ED as a family medicine boarded doc. However, your job opportunities may be limited as an attending.

There are plenty of negatives to EM. It’s important to think about what you like the best about a specialty and what you hate the least.

Thank you for reading! I would be happy to answer any additional questions. Also, any feedback would be greatly appreciated.

 

Resources for medical students

  • reddit.com/r/medicalschool
  • NRMP match data
  • Student Doctor Network – emergency medicine thread
  • Cordem.org/esloe
  • ACEP’s annual compensation report

 


 

Again, if you haven’t checked out part one, click here: The Med Student’s Guide to Emergency Medicine (Part 1)

For all updates, follow me on Twitter: @JordanSoze

The Med Student’s Guide to Emergency Medicine (Part 1)

Jordan Soze here. Today we’re featuring a guest post from a good friend of mine who will be contributing more in the future. Zesty Mordton is a fourth year medical student who recently matched into a top emergency medicine program (congrats again my dude). Furthermore, I’ve known him since high school where we bonded over music (and even saw Radiohead together). Dude is brilliant and one of the nicest guys you’d ever meet. By some struck of luck, he happened to be in the class above me in my medical school where he’s been an invaluable mentor during my journey. Naturally, in the twilight of his medical school career, I asked him if he’d like to contribute some of that sage wisdom to Soze Media and he delivered this absolute gem of a post.

If you’re considering applying to emergency medicine or simply want to know what it’s all about, read this post. Bookmark it. Save it. And read it again. It’s an in depth exploration into choosing emergency medicine as a career and the application process, so I’ve split the post into two parts. In part one, he discusses why he chose emergency medicine, what type of students should consider EM, and gives insight into the specialty. In part two, he gives priceless advice on applying to emergency medicine, including competitiveness, audition rotations, SLOEs, how to impress, and so on. Enjoy! 


Hey, everyone! I’m Zesty Mordton and I’m honored to be the first guest contributor to Soze Media. I went to high school and medical school with Soze, and after talking recently, he asked if I’d write a bit about emergency medicine (EM) for those interested in the field. I recently matched into EM and am excited to share some info about the field. Big thanks to Soze for letting me contribute to this great blog.

Let’s dive in!

Why EM?

The quick of it? I wanted a high-acuity field, no personal patients (clinic, continuity of care, etc.), short residency length (I have a boat load of student loan debt), shift-work with no call, and a specialty that I felt meshed with my personality.

For more detail, I think it’d be best to walk through my decision process.

Most students are told that the first decision they need to make is surgery vs. non-surgery. This is reasonable, but the first step I made is whether I wanted acute or non-acute patients. Now all fields of medicine tend to deal with acutely ill patients at some point. But some deal with sick patients more than others.

After my rotations, I considered the most acute fields to be the following:

EM, general surgery, neurological surgery, OB/GYN, orthopedic surgery, anesthesia, critical care fellowship (via multiple residency routes)

After choosing high-acuity, I next decided if I wanted “my own” patients (i.e. clinic and/or patient follow up) or not. Deciding I did not want continuity of care or “my own” patients, I was left with EM, anesthesia, and some critical care options.

Knowing critical care could be achieved through EM and anesthesia, I narrowed it to those two options. You can grab a critical care fellowships a bunch of different ways. I won’t go into all of the options here, but basically EM and anesthesia were the shortest tracts and I enjoyed their “bread and butter” practice more than any other residency. A critical care attending once told me to choose a field based on the residency, not the fellowship options. I think there is some truth to that, just in case you don’t end up getting that fellowship position.

Okay, so why EM? EM residency is three years, it’s shift work with no call, I’m not constantly working with surgeon and their schedules, there’s great variety in practice, and I was apprehensive about CRNAs and the shift of “bread and butter” anesthesia to a more managerial role. 

Lastly, throughout my rotations, I seemed to mesh well with EM physicians and residents more than any other field (anesthesia was a mighty close second though). More on this in a bit.

On a side note, I want to stress that it was my personal experience that drove all of these decisions. Some students might have completely different rotations and think EM is just exaggerated primary care or that CRNA involvement has been overblown for years now (though I do think it is safe to say general anesthesia is shifting to more of a managerial role). You may also disagree with the specialties I consider high-acuity. Either way, I strongly encourage each student to judge specialties based off their own experience, not the generalized experience of others. Don’t exclude surgery because you hear the lifestyle is bad. Don’t include dermatology because you hear the lifestyle is great. Find out for yourself.

EM negatives

The two biggest negatives I hear from residents and attendings are the lack of respect and the high amount of expectation management.

Being an EM physician, you are the second best at everything in the hospital. Intubation? Not as good as anesthesia. Suturing? Not as good as plastics/surgery. EKG interpretation? Not as good as cardiology. The only acception is probably resuscitation.

This second best status doesn’t give you a whole lot of pull in the hospital. Related to this is the fact that you’re going to be calling consults left and right. Ortho, medicine, surgery, cardiology, OB, etc. They’re all going to be woken up at 2AM by your phone call. Even more, you aren’t going to work up their consults exactly how they want. I don’t say this to try and point out how consult services are picky. I say this because EM physicians might forget things and might not work up patients as well as a cardiologist or OB would. This is because while the pre-eclamptic patient is in room 3, a dilated cardiomyopathy is in room 16, and two motorcycle collisions are in the trauma bays. You have so much going on that you will rule out the serious stuff, consult for the details, and try to keep your head above water. It’s just a lack of understanding for what other specialties deal with, just as EM has for other fields themselves (why did that family medicine doc tell the patient to come to the ED?).

This lack of respect may turn some people off. There’s a very good chance your clinical acumen and decision making will be called into question by others on a daily basis. This doesn’t bother me, but does bother a considerable amount of people (for better or worse).

The other aspect of this field that might be a turn off is the amount of expectation management. Some patients think the ED is a place to get an antibiotic for their URI, or to be admitted for their sprained ankle, or get opioids for their low back pain. A big part of your job is to listen to the expectation, and then explain how this will differ from your plan. This can lead to a lot of unpleasantness and difficult patient interaction. I think this is common in plenty of other fields, but not quite in the same quantity as EM.

There are plenty of other reported EM cons. High burn-out, shift work with alterations of day and night shifts, working weekends and holidays, mid-level encroachment, no continuity of care, EM doesn’t make money for the hospital, wide misuse of the ED for primary care, etc. But again, I wanted to talk about some of the most common cons I hear from other students and residents.

In the end, none of these cons bothered me too much. I think there is some merit in not only considering what you like the best, but what you hate the least.

What type of students should consider EM?

EM typically attracts students who are calm under pressure, love procedures, and who prefer shift work.

The ED is a hectic place. You are managing multiple patients at any given time and the variety of pathology spans across every medical field. Even more, some of the patients are actively dying.  There is definitely truth in the adage of EM being the most exciting fifteen minutes of every medical specialty. This results in a high-stress environment on a daily basis. EM docs have to be calm and collected under pressure. Some argue you have to love this frantic aspect of EM, want the adrenaline, etc. While it would help, I don’t think that is true. You simply have to be able to handle it.

The two other aspects that interest students are the high volume of procedures and shift work. You’ll see suturing, intubations, central lines, chest tubes, I&Ds, fairly regularly. You will probably even see a thoracotomy or canthotomy. You will also work either eight, ten, or twelve hour shifts. This is appealing to a lot of students as you don’t take call and your schedule is very predicable. When you’re on, you’re on. When you’re off, you’re off.

Besides these three main characteristics, students may like EM for the reasons I mentioned above in ‘Why EM?’. They also might be attracted to the “chill” factor. For some reason, emergency medicine seems to interest laid back, easy-going physicians. No yelling, no malicious pimping, and relaxed conversation. While I’m sure this isn’t true for all hospitals, it seems to be the general consensus with every hospital I’ve been and with other medical students. 

What qualities to look for in programs?

I don’t think this differs from any other residency.

With the strict regulations imposed by ACGME, you will get a solid education in pretty much any residency program. The biggest thing to assess is how well you fit with faculty and residents in a given program.

With that being said, there are three general types of EM programs out there that may pique your interest. They are academic, county, and community.

Academic programs are affiliated with a university and have great research exposure, fellowship opportunities, and teaching opportunities. They are affiliated with huge tertiary referral centers and arguably see the rarest pathology out there. Think Johns Hopkins, Ohio State, etc.

County programs tend to deal with low-income, underserved patient populations. And, from my experience, these programs deal with the sickest patients in EM. They are usually no-frill, efficient facilities that see over 100,000 patients a year and are pros at trauma, psych, and patients who haven’t seen a doctor in decades. Think LAC/USC, Cook County, etc.

Community programs are typically non-leveled or lower-leveled trauma centers that take care of a middle or high-class patient population. They tend to get some sick patients, but not as much as county programs. And they tend to get some research/teaching opportunity, but not as much as academic programs. There are definitely exceptions, but as a rule of thumb, I would put them in the middle of the spectrum between academic and county. The big draw here is that the vast majority of EM physicians will work at community hospitals. So this arguably prepares you best for the type of practice you’ll find yourself in after you complete residency.

Not all programs fit nicely into one of these three categories. Some places are level I trauma, big centers that are community-based. Some programs may be a combination of university and county. But this is still a useful way to generally categorize programs and things you might like about them.

The thing with these three main program types is that the ACGME has stipulations in place so you get exposed to everything. For instance, you have to do a research project in order to graduate. You have to complete so many procedures to graduate (most community hospitals have an agreement with big level I trauma centers, which are typically academic or county, so residents can do a trauma or ICU rotation with them for exposure to high-acuity procedures). Lastly, big academic and county centers have rotations at small community hospitals so you are exposed to that patient population and pace of medicine.

All in all, while the type of program does matter, you will get exposed to most everything no matter what kind of residency you end up attending. Therefore, the support and fit of the program’s personnel is most important to your choice.

Stay tuned for part 2!

Med School Memoirs: Smell the Roses

Another entry into the Med School Memoirs series. Wrote this yesterday. Haven’t edited it and don’t know if it’ll make the book I’m feeling good right now so I’m posting it. Enjoy.


 

Smell the Roses.

I skimmed my book with a blue sharpie pen in hand while he muttered notes from the morning’s final operation into the Dragon speech recognition microphone. Occasionally he’d pause and say something and I’d perk up and look at him as if he were speaking to me only to realize he’d just resumed dictating his post-op notes. After multiple rounds of this “is he speaking to me or the computer” game, his head turned towards me. I closed my book and looked up at him. This was the real deal. He asked, haven’t you finished that book yet?

Yes, I said. I’m just going through it again. I want to make sure I learn as much as possible before my audition rotations.

Put it away, he said. Let’s get some lunch. He stood up from his computer and I followed him down the hospital corridor. He pulled his surgical mask from his neck and threw it in the trash. I did the same. You’re smart and you work hard, he continued. You’re going to make it.

Thanks doc, I replied. I just… it’s stressful, you know? I feel like time’s flying.

He nodded and continued walking without a reply. His lack of response made me wonder if what I said had sounded stupid to him. I cared what he thought about me, which led me to overthink many of the things I said to him. He was an intelligent and accomplished surgeon, which is what I hope to be. Some day.

We walked side by side; I was on the left and he was on the right. He turned left into me towards the stairwell door and we did that awkward thing where you’re in someone’s way and you have a western gun draw about which way you should move to actually get out of the way. That’s the thing about being a med student; you’re either in the way or invisible. Today I was in the way.

(more…)

Announcement: Med School Memoirs.

Welcome. Let’s get to it.

I have been trying to write this post for months but I never seem to find the right words.  Several times per week, I’ll write this post and delete it.  I can’t write anything on this site anymore.  But I need to just finish this and post it so that I can jump over that mental hurdle.  So, I’ll skip the flowery introduction and get the purpose of this post immediately.

While I haven’t been posting much on Soze Media lately, I have been writing. In fact, have been writing more than ever. But I’m not writing end of rotation reviews, or how-to lists, or anything of that nature. Rather, I’m writing a book.  For now, the working title is “Med School Memoirs”.

It is a collection of short stories. Many are real, others are fiction, and some blur the line between the two. I was going to try to explain the stories but I can’t seem to do it. Some stories are directly about being a medical student, while others simply take place in the setting of medical school.

When I started writing them, I had no intention to share them, meaning I could write without worrying what readers may think – which is the best way to write and stay true to your voice. My site grows in popularity and page views every month, but I haven’t posted any of these stories due to the fear that no one will care. The whole “putting yourself out there” thing, you know? It gives me anxiety.

But since I’m finally posting this announcement, I know that it must come with a teaser. I’ve written over 50 stories, and I’ll write 50 more, but the book will be a selection for 30 or so of the best stories. Therefore, once in a while until I release the book (likely early 2020), I’ll post a story that won’t make the final product and will be left on the cutting room floor. Here’s one such story, a tale of loneliness, isolation, and love.  It’s the story of my old friend and neighbor, Raj.

Med School Memoirs: Str8 Outta Mumbai

 

Twitter: @JordanSoze
Email: collegesoze@gmail.com

More to come.